3302 HSA PDF

TRANSFER REQUEST PART 1. RECIPIENT PART 2. ACCEPTING HSA TRUSTEE OR CUSTODIAN Individual requesting the transfer To be completed by the. – HSA Contribution / Investment. Open PDF SU – HSA Beneficiary Designation Addendum. Open PDF – HSA Transfer Request. Open PDF. I authorize the transfer of the HSA assets in the manner described above and certify that all of the information provided by me is correct and may be relied upon .

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Consumer Directed Health Plan (CDHP) & Health Savings Account (HSA)

Hospice Care Room and board in a licensed facility or in your home; services of medical personnel; others services and supplies. Outpatient Mental Health and Substance Abuse Outpatient hsw crisis intervention; detoxification. It is important to keep in mind that you can only use HSA funds after you have contributed them.

Y ou can count on support from usa and responsive HR has when you have a benefits question or problem. Please call Aetna toll free at or contact the Benefits Team at for additional information.

Plan pays for up to seven visits during first year for well-child care, PSA, and tests and well—woman care office visits. You must call Aetna at at least 14 days in advance of nonemergency treatment to request precertification or you will have no coverage.

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Qualified medical expenses that may be paid through your HSA on a tax-free basis include most medical care and services; dental and vision care; prescription drugs; and premiums paid for COBRA, long-term care, and medical and prescription drug expenses as a retiree, including Medicare premiums.

Durable Medical Equipment Purchase nsa Rental Splints, braces, nonsurgically implanted prostheses, specified medical equipment for use in the home. Inpatient Mental Health and Substance Abuse 4.

Any money you withdraw from your HSA to spend on healthcare expenses is tax free. The chart below provides a brief overview of the benefits offered. Emergency Room Care Services administered for conditions meeting the definition of an emergency. The amount you must pay if you do not call Medical Management at before hospitalization and certain types of surgery, or fail to follow concurrent review procedures.

The amount you pay each year before the plan begins covering particular medical expenses. The money you put hsq an HSA is deducted from your pay before taxes. Nonemergenices are not covered. Family deductible is cumulative.

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Anesthesia and use of an operating room or related facility in a hospital or authorized institution. Short-term physical, speech, occupational or pulmonary and cardio rehabilitation therapies. Hearing Exam 1 exam per calendar year; coinsurance, deductible or copayment applies. You can see hsaa complete list of eligible expenses at www. Just call or send us an e-mail.

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Your unused balance accumulates year after year. Preventive Care Preventive physicals, well-child care including scheduled immunizations Plan pays for up to seven visits during first year for well-child care, PSA, and tests and well—woman care office visits. You can contribute money to your HSA on a pretax basis through payroll deductions. Splints, braces, nonsurgically implanted prostheses, specified medical equipment for use in the home.

You will be responsible for out-of-network precertifications. Physician Services Performed in an Office Setting Primary care office visits for routine care; diagnosis and treatment of an illness or injury.

Primary care office visits for routine care; diagnosis and treatment of an illness or injury. Hsx Prescription Drug Program is included with this plan. Dialysis, Chemo, and Radiation Services.

Outpatient Physical Rehabilitation Short-term physical, speech, occupational or pulmonary and cardio rehabilitation therapies. You can manage your HSA at www. Outpatient Lab Services for Diagnosis or Treatment.

Deductible The amount you pay each year before the plan begins covering particular medical expenses. The HSA allows you to accumulate savings and carry over year after year.